Combined depth imaging of choroid in uveitis

Background

Understanding the changes that occur in the choroid is of paramount importance in various uveitis entities. B-scan ultrasonography and indocyanine green angiography can be used to study choroid. Currently, spectral-domain optical coherence tomography is used as the standard noninvasive technique to study the choroid by enhanced depth imaging.

Our aim was to study the structural visibility of the choroid using spectral-domain optical coherence tomography in the same area of interest in patients with uveitis with posterior segment manifestations using conventional, enhanced depth imaging (EDI), and combined depth imaging (CDI) techniques.

Results

Fifty-eight (58) eyes of 48 patients between age group 9 and 82 years were confirmed cases of uveitis. Out of the 48 patients, 21 (43.75%) were males while 27 (56.25%) were females. Sixteen eyes (27.59%) had intermediate uveitis, 33 (56.9%) had posterior uveitis, and 9 eyes (15.51%) had panuveitis.

For posterior vitreous, there was substantial agreement for all the three groups (kappa value of 0.77, 0.73, and 0.72 in groups 1, 2, and 3, respectively). For vitreo retinal interface and inner choroid, there was perfect interobserver agreement, and for outer choroid, there was substantial to almost perfect interobserver agreement (kappa value of 0.71, 0.81, and 0.86 in groups 1, 2, and 3, respectively).

Chi-squared test was done to compare the three groups. The method of scanning had a significant effect on the visualization of posterior vitreous and the outer choroid (p < 0.01) and did not have an effect on the visualization of vitreoretinal interface, inner retina, outer retina, and inner choroidal layers (p > 0.05).

Conclusion

The CDI technique alone might provide a good structural visibility compared to normal and EDI scanning done separately in patients with uveitis with posterior segment pathology. CDI OCT technique is thus able to visualize all posterior structures in a single image in patients with uveitis with posterior segment manifestations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12348-014-0018-8) contains supplementary material, which is available to authorized users.

Medical management of uveitis - current trends

Uveitis is a challenging disease to treat. Corticosteroids have been used in the treatment of uveitis for many years. Immunosuppressives are gaining momentum in recent years in the treatment of uveitis. In this article we present an overview of current treatment of uveitis and the major breakthroughs and advances in drugs and ocular drug delivery systems in the treatment of uveitis.

Chikungunya and the eye: a review

Chikungunya is a self-limited, systemic viral infection that has been a major health problem since the past few years. Ocular manifestations of the disease have become more prevalent in the recent years. Currently, there is neither a specific treatment nor vaccine available for chikungunya fever. This review highlights the current understanding on the pathogenesis, systemic changes with an emphasis on ocular findings, laboratory investigations, and prevention and treatment of this disease.

Anterior segment optical coherence tomography findings of iris granulomas in Hansen's disease: a case report

Background

A 50-year-old male was diagnosed to have a right eye sclerouveitis and left eye granulomatous anterior uveitis due to Hansen's disease. We are reporting the anterior segment optical coherence tomography (ASOCT) findings of iris granuloma in this case.

Findings

Skin biopsy revealed plenty of acid fast bacilli with a bacteriological index of 5 suggestive of multibacillary polar lepromatous leprosy. ASOCT revealed well-demarcated smooth-surfaced nodular lesion with internal hyporeflectivity corresponding to the areas of granuloma which decreased in size following treatment with antileprosy drugs and systemic and topical steroids.

Conclusion

ASOCT is a non-invasive technique to assess the extent of involvement of anterior segment in Hansen's disease and is a useful tool in follow-up. This is also the first report on ASOCT findings of iris granuloma in Hansen's disease.

High definition spectral domain optical coherence tomography of retinal pigment epithelial rip in a case of sympathetic ophthalmia

Background

We are reporting a case of granulomatous panuveitis in the right eye following penetrating injury to the left eye.

Findings

A 34-year-old female was diagnosed to have sympathetic ophthalmia on treatment with systemic steroids. Vision did not improve in spite of aggressive systemic steroid therapy. On examination, patient had large retinal pigment epithelial rip nasal to the disc with exudative retinal detachment which was documented with FFA, ICG, and OCT. RPE rip is responsible for the persistent exudative retinal detachment in the right eye.

Conclusions

RPE rip can cause decreased vision due to persistence of retinal detachment in a case of sympathetic ophthalmia.

Three-year visual and anatomic results of administrating intravitreal bevacizumab in inflammatory ocular neovascularization

OBJECTIVE

To assess the 3-year visual outcome of intravitreal bevacizumab in inflammatory ocular neovascularization.

DESIGN

Experimental study.

METHODS

Retrospective multicenter consecutive case series in 81 patients with inflammatory ocular neovascularization refractory to standard therapy and treated with intravitreal bevacizumab. The outcome measures included improvement of best corrected visual acuity expressed as logarithm of minimum angle of resolution (logMAR) and paired comparison decrease in central foveal thickness by optical coherence tomography.

RESULTS

Mean best corrected visual acuity improved from baseline 0.699 (6/30 or 20/101) (SD 0.434) to 0.426 (6/16 or 20/53) (SD 0.428) (n = 81; p < 0.001), a gain of 2.7 lines (median 3 injections; 81 eyes; 81 patients). Paired comparisons revealed significant central foveal flattening at 3 years of 97.9 μm (n = 51; p < 0.001). In a subgroup analysis, visual improvement was significant for ocular histoplasmosis (p = 0.026); multifocal choroiditis (p = 0.05); serpiginous choroiditis (p = 0.028); ocular toxoplasmosis (p = 0.042); and punctate inner choroidopathy (p = 0.015). In a subgroup analysis, foveal flattening was significant for ocular histoplasmosis (p = 0.004); multifocal choroiditis (p = 0.007); serpiginous choroiditis (p = 0.011); and punctate inner choroidopathy (p = 0.001). Of the group, 5 eyes developed submacular fibrosis, 1 eye retinal pigment epithelial tear, and 1 eye macular ischemia in the context of vasculitis.

CONCLUSION

At 3 years, intravitreal bevacizumab sustained significant visual improvement of 2.7 lines and significant foveal flattening of 98 μm in a wide variety of inflammatory ocular diseases without major complications after a median of 3 injections.

Five-year visual results of intravitreal bevacizumab in refractory inflammatory ocular neovascularization

Purpose

To assess the 5-year visual outcome of intravitreal bevacizumab in inflammatory ocular neovascularization.

Methods

Retrospective, multicenter, consecutive case series of eight patients with inflammatory ocular neovascularization refractory to standard therapy who were treated with intravitreal bevacizumab and followed for 5 years after first injection. The outcome measures included improvement of best-corrected visual acuity expressed as logarithm of minimum angle of resolution.

Results

Mean best-corrected visual acuity significantly improved from 0.58 at baseline (6/23 or 20/76; standard deviation = 0.32) to 0.20 at final assessment (6/10 or 20/32; standard deviation = 0.25) (n = 8; P = 0.02), a gain of 3.8 lines (median: three injections; eight eyes; eight patients). No ocular or systemic complications from intravitreal bevacizumab were noted.

Conclusion

At 5 years, intravitreal bevacizumab sustained significant visual improvement in ocular neovascularization due to a variety of inflammatory ocular diseases without major complications after a median of three injections.

Unilateral conjunctival ulcer due to Stenotrophomonas maltophilia infection

We report a case of unilateral conjunctival ulcer due to Stenotrophomonas maltophilia infection in an immunocompetent individual. A 44-year-old male presented with complaints of pain and yellowish discharge in the right eye for one week. Patient underwent complete ophthalmic evaluation and relevant laboratory investigations. Anterior segment examination revealed localized conjunctival and episcleral congestion with conjunctival ulceration on the bulbar conjunctiva in the right eye. Gram's stain revealed gram-negative bacilli. Culture and sensitivity revealed S. maltophilia and responded well to topical moxifloxacin with systemic co-trimoxazole therapy.

Understanding clinically undetected macular changes in early retinopathy of prematurity on spectral domain optical coherence tomography

PURPOSE

To investigate macular changes in acute retinopathy of prematurity (ROP).

METHODS

Fifty-four premature infants with ROP and 20 controls underwent routine ROP screening with indirect ophthalmoscopy and imaging. A tabletop spectral domain optical coherence tomography (SD-OCT) scanner (Spectralis; Heidelberg Engineering, Heidelberg, Germany) was converted into a handheld device to image infants in the office sans sedation.

RESULTS

SD-OCT images were obtained in all infants in the office. On SD-OCT, 23 of 79 eyes (29.1%) with stage 2 ROP showed abnormal foveal changes despite clinically normal foveae. Of the 23 eyes, 2 distinct patterns of foveal involvement were observed: "pattern A," which was characterized by dome-shaped foveal elevation and cystoid spaces with highly reflective intervening vertical septae, and "pattern B," which was characterized by preservation of the foveal depression with fewer intraretinal cystoid spaces. These patterns were seen in 12 (52.2%) and 11 (47.8%) eyes, respectively. All eyes (100%) belonging to stage 1 ROP (27) and the normal group (40) had no abnormal SD-OCT changes. The mean central foveal thickness was 156.9 ± 28.3 μm, 206.5 ± 98.7 μm, and 135.9 ± 17.6 μm for stage 1, 2, and normal eyes, respectively (P < 0.001). Nineteen of the 23 eyes underwent serial imaging at 52 weeks' postmenstrual age (PMA), and all of them revealed normalization of foveal contours at this visit.

CONCLUSIONS

SD-OCT changes of the macula in mild ROP have not been previously described. Our method reveals that infants may be imaged supine and unanesthetized in the office. We hypothesize that these transient foveal changes at the critical time of fovealization in premature infants may influence their visual acuity in the adult life.

Chikungunya virus iridocyclitis in Fuchs' heterochromic iridocyclitis

We are reporting a case of bilateral Fuchs’ heterochromic iridocyclitis with chikungunya virus infection in the left eye. A 20-year-old female was presented with a past history of fever suggestive of chikungunya with bilateral Fuchs’ heterochromic iridocyclitis and complicated cataract. She had a tripod dendritic pattern of keratic precipitates by confocal microscopy in the left eye with a stippled pattern of keratic precipitates in both eyes. The real-time polymerase chain reaction (RT-PCR) assay in the aqueous humor detected 98 copies/ml of chikungunya virus RNA. The patient underwent clear corneal phacoemulsification with in-the-bag intraocular lens implantation in the left eye with a good visual outcome. This is the first report where the presence of chikungunya virus RNA has been associated with a case of bilateral Fuchs’ heterochromic iridocyclitis.

Retinal vasculitis as an early indicator of systemic candidal abscesses in a premature infant

We report a case of fungal retinal vasculitis in a 32 week gestational age, 1200 g premature infant detected during routine screening for retinopathy of prematurity at 78 days of age. The patient subsequently developed sepsis with perinephric abscess but responded rapidly to systemic therapy. Fortuitous detection of retinal vasculitis as the first evidence of a systemic fungal infection in an immunocompetent and asymptomatic infant has not, to our knowledge, been previously reported.

Retinal vascular events after intravitreal bevacizumab

PURPOSE

To record retinal vascular events following intravitreal bevacizumab injection.

METHODS

Collaborative multi-centre retrospective case series.

RESULTS

Eight patients were documented to have central retinal artery occlusion (four patients), branch retinal artery occlusion, capillary occlusion, central retinal vein occlusion and branch retinal vein occlusion (one patient each) within 0-55 days (median 2 weeks) of intravitreal bevacizumab. All patients had several ocular and systemic risk factors for retinal vascular events: elevated intraocular pressure on discharge (four patients), pre-existent glaucoma (one patient), pre-existent ischaemic retinal vascular disorder (four patients), systemic hypertension (five patients), diabetes mellitus (three patients), coronary artery disease (four patients), carotid disease (three patients), smoking (two patients) and migraine (one patient).

CONCLUSION

The retinal vascular events may be associated with the underlying ocular disease under treatment or with the underlying systemic disease, may be related to an increased intraocular pressure post-injection constraining further an already poor retinal perfusion, the vasoconstrictor effect of bevacizumab, or a combination of all three.

Polycythemia vera and increased hemophilic factor VIII causing acute zonal occult outer retinopathy: a case report

OBJECTIVE

To report a case of acute zonal occult outer retinopathy (AZOOR) caused by Polycythemia and increased levels of Factor VIIIC.

DESIGN

Case Report - Interventional.

METHODS

We present a 23 year old male with blurring of vision and loss of lower visual fields in both eyes. Ocular examination suggested the possibility of AZOOR that was confirmed with Fluorescein Angiogram, Visual fields and Electroretinogram. Laboratory work up revealed polycythemia with increased Factor VIIIC. He was treated for the same.

RESULTS

Ocular symptoms improved within 24 hours of treatment with venesection and asprin.

CONCLUSIONS

Polycythemia vera and increased factor VIIIC levels, both venous thromboembolic risk factors are treatable causes of AZOOR.

Long-term visual outcomes of intravitreal bevacizumab in inflammatory ocular neovascularization

PURPOSE

To assess the long-term role of bevacizumab (Avastin; Genentech Inc, South San Francisco, California, USA) in inflammatory ocular neovascularization.

DESIGN

Retrospective multicenter consecutive case series of inflammatory ocular neovascularization.

METHODS

settings: Multicenter institutional and private practices.

STUDY POPULATION

Patients with inflammatory ocular neovascularization in one or both eyes of varying etiologies who failed standard therapy. intervention: Intravitreal injection of bevacizumab.

MAIN OUTCOME MEASURES

Improvement of best-corrected visual acuity (BCVA) expressed as logarithm of minimal angle of resolution (logMAR), and decrease in central foveal thickness as measured by optical coherence tomography at 6, 12, 18, and 24 months of follow-up.

RESULTS

Mean logMAR BCVA (central foveal thickness) following intravitreal bevacizumab was as follows: baseline, 0.65 (6/27 or 20/90) (338 microm; 99 eyes of 96 patients); 6 months, 0.42 (6/16 or 20/53) (239 microm; 2.0 injections; 81 eyes); 12 months, 0.39 (6/15 or 20/49) (241 microm; 2.3 injections; 95 eyes); 18 months, 0.40 (6/15 or 20/50) (261 microm; 3.0 injections; 46 eyes); and 24 months, 0.34 (6/13 or 20/44) (265 microm; 3.6 injections; 27 eyes). Paired comparisons revealed significant visual improvement at 6 months of 2.4 lines (P = .000), at 12 months of 2.5 lines (P = .000), at 18 months of 2.5 lines (P = .001), and at 24 months of 2.2 lines (P = .013). Paired comparisons revealed significant central foveal flattening at 6 months of 78 microm (P = .000), at 12 months of 85 microm (P = .000), at 18 months of 90 microm (P = .003), and at 24 months of 77 microm (P = .022). Three eyes developed submacular fibrosis and 1 eye submacular hemorrhage.

CONCLUSION

Intravitreal bevacizumab led in the long-term to significant mean visual improvement of > or =2.2 lines and significant foveal flattening in a wide variety of inflammatory ocular diseases without major complications.

Intravitreal bevacizumab in inflammatory ocular neovascularization

PURPOSE

To assess the role of bevacizumab in inflammatory ocular neovascularization.

DESIGN

Retrospective, multicenter, consecutive case series of inflammatory ocular neovascularization.

METHODS

Patients with inflammatory ocular neovascularization of varying causes for whom standard therapy failed were treated with intravitreal injection of bevacizumab. Main outcome measures included improvement of best-corrected visual acuity (BCVA) expressed in logarithm of minimum angle of resolution units, response of inflammatory ocular neovascularization by funduscopy and angiography, and decrease in central foveal thickness as measured by optical coherence tomography at the three-month follow-up.

RESULTS

At the three-month follow-up, 84 eyes of 79 patients had been treated with a mean of 1.3 injections (range, one to three). Thirty-four eyes showed juxtafoveal choroidal neovascularization (CNV), 34 eyes showed subfoveal CNV, eight eyes showed peripapillary CNV, and 11 eyes showed neovascularization of the disc (NVD) or neovascularization elsewhere (NVE). BCVA improved 2.4 lines from 0.68 (6/28 or 20/94) to 0.44 (6/17 or 20/55) (P < .001). BCVA improved by one to three lines in 34.5% of the eyes, by four to six lines in 16.7% of the eyes, and by more than six lines in 14.2% of the eyes. Function was unchanged in 23.8% of the eyes. BCVA worsened in 10.7% (zero to three lines in 7.1%, more than four lines in 3.6%). Central foveal thickness decreased from baseline 346 to 252 microm (P < .001). For CNV, 32 eyes (43.2%) had complete regression after the injection, 27 (36.5%) had partial regression, five (6.8%) had no response, and 10 eyes (13.5%) were not evaluated by the contributors. For NVD or NVE, seven eyes (63.6%) had complete regression of new vessels and four eyes (36.4%) had partial regression after the injection.

CONCLUSIONS

Intravitreal bevacizumab led to short-term significant visual improvement and regression of inflammatory ocular neovascularization in a wide variety of inflammatory ocular diseases.

Fibrinous anterior uveitis due to cysticercus cellulosae

PURPOSE

To report a case of fibrinous anterior uveitis due to cysticercus cellulosae in anterior chamber.

DESIGN

Retrospective, interventional case study.

METHODS

Patient underwent complete ophthalmic and systemic evaluation with relevant investigations. Viscoexpression of anterior chamber cysts were done under general anaesthesia.

RESULTS

A 10-year-old male child presented as unilateral fibrinous iridocylitis with secondary glaucoma. Two cysts of cysticercus cellulosae were seen after control of inflammation. Complete resolution of uveitis occurred once the cysts were removed by viscoexpression.

CONCLUSION

Cysticercus cellulosae can present as fibrinous anterior uveitis with secondary glaucoma. Removal of the cyst can cause complete resolution of uveitis.

Serpiginous choroiditis-like picture due to ocular toxoplasmosis

PURPOSE

To report an atypical presentation of ocular toxoplasmosis in the form of serpiginous choroiditis-like picture in an immunocompetent individual.

METHODS

CASE REPORT

A 32-year-old man with blurred vision in the left eye showed serpiginous choroiditis-like appearance. Fundus fluorescein angiography and relevant laboratory tests including anti-toxoplasma serology and polymerase chain reaction (PCR) in aqueous humor were performed.

RESULTS

The serology in blood and PCR in aqueous humor were positive for Toxoplasma gondii infection. The patient was treated with anti-toxoplasma antimicrobials and systemic steroids. At the end of six weeks of treatment the fundus lesions had healed well, with good visual recovery.

CONCLUSIONS

Serpiginous choroiditis-like picture can be an atypical manifestation of ocular Toxoplasma gondii infection.

Ocular manifestations associated with chikungunya

PURPOSE

To report ocular manifestations associated with chikungunya.

DESIGN

Retrospective, nonrandomized, observational case series.

PARTICIPANTS

Nine chikungunya patients with ocular involvement.

METHODS

All patients with chikungunya infection presenting with ocular complaints from September 2006 to October 2006 were included in the study. The infection was confirmed by demonstration of chikungunya immunoglobulin M antibody in sera of all patients. All patients underwent an ophthalmic examination including fundus photography, fundus fluorescein angiography, confocal microscopy of keratic precipitates, and optical coherence tomography. Positive ocular changes were recorded and tabulated.

MAIN OUTCOME MEASURES

Characteristics, frequency, and locations of ocular lesions found in the participants.

RESULTS

There were 9 patients with ocular lesions; 1 had nodular episcleritis, 5 presented with acute iridocyclitis, and 3 had retinitis. Four to 12 weeks before the development of ocular manifestations, all of these patients had fever. Although there were no specific changes of iridocyclitis that were diagnostic of the fever, the retinal changes were consistent with viral retinitis. All patients recovered from the infection with relatively good vision.

CONCLUSION

It appears that iridocyclitis and retinitis are the most common ocular manifestations associated with chikungunya, with a typically benign clinical course. Less frequent ocular lesions include episcleritis. All the patients responded well to the treatment with preservation of good vision. To the best of our knowledge, similar ocular manifestations associated with chikungunya infection have not been reported. In the differential diagnosis of iridocyclitis and retinitis with features suggestive of a viral infection, the entity of chikungunya-associated ocular changes should be considered in the regions affected by the epidemic.